Burn reconstruction: the problems, the techniques, and the applications

Burn Scar Management and Reconstructive Surgery

This chapter highlights the importance of a comprehensive burn scar treatment plan in approaching a burn survivor. General concepts of burn scar physiology and a practical system to describe burn scars based on cause, biology, and symptoms are presented. Common scar management modalities including nonsurgical, surgical, and adjuvant therapies are further discussed.

The dermal papilla dilemma and potential breakthroughs in bioengineering hair follicles

The generation and growing of de novo hair follicles is the most daring hair replacement approach to treat alopecia. This approach has been explored at least since the 1960s without major success. Latest in the 1980s, the realization that the mesenchymal compartment of hair follicles, the dermal papilla (DP), is the crucial signaling center and element required for fulfilling this vision of hair follicle engineering, propelled research into the fibroblasts that occupy the DP. However, working with DP fibroblasts has been stubbornly frustrating. Decades of work in understanding the nature of DP fibroblasts in vitro and in vivo have led to the appreciation that hair follicle biology is complex, and the dermal papilla is an enigma. Functional DP fibroblasts tend to aggregate in 2D culture, while impaired DP cells do not. This fact has stimulated recent approaches to overcome the hurdles to DP cell culture by mimicking their natural habitat, such as growing DP fibroblasts in three dimensions (3D) by their self-aggregation, adopting 3D matrix scaffold, or bioprinting 3D microstructures. Furthermore, including keratinocytes in the mix to form hair follicle-like composite structures has been explored but remains a far cry from a useful and affordable method to generate human hair follicles in sufficient quantity and quality in a practical time frame for patients. This suggests that the current strategies may have reached their limitations in achieving successful hair follicle bioengineering for clinical applications. Novel approaches are required to overcome these barriers, such as focusing on embryonic cell types and processes in combination with emerging techniques.

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

Effect of autologous fat transfer in acute burn wound management: A randomized controlled study

OBJECTIVE

The use of fat grafting is being widely used for different indications one of which is wound healing. In this study we compare the use of autologous fat grafting (AFG) as a novel indication in acute burn wounds healing and burn scarring to the conventional methods of burn wound management both clinically and histologically. Several small observational studies demonstrated the effect of the AFG in healing of chronic wounds, different vascular ulcers or effect on scars yet no randomized controlled trial is available to compare its role with conventional methods.

METHODS

The study was a prospective, open-label single center, randomized control clinical trial included 100 patients with superficial and deep dermal burns from March 2019 to March 2020 randomized to AFG protocol consisted of a single injection of autologous fat grafting then dressed with nano fat (Group A) or conventional methods of serial dressings with 1% silver sulphadiazine or other topical agents (Group B). Inclusion criteria included newly admitted burn patients with affected total body surface area (TBSA) (10%-25%) while exclusion criteria included burns patients with affected TBSA of< 10% or> 25%, or loss of subcutaneous fat, fascia, muscles and bones, inhalational burn, and burns in genitalia, perineum and peri-anal areas and co-morbidity(ies) that might affect wound healing or eligibility for anaesthesia and surgery. Also, results were confirmed by histological analysis for samples from both groups by light microscopic examination, and the nano-fat was subjected to flow cytometric analysis of the cluster of differentiation (CD) markers of mesenchymal stem cells markers CD 90, CD44, CD45, CD 73, and CD 34. (ClinicalTrials.gov Identifier: NCT03791710) RESULTS: We found a significant reduction in total hospital stay days (p = <0.001), less further skin grafting (p = 0.003), less contracture formation (p = <0.002) while scar texture improved (p = <0.001) in group A compared to group B. Flow cytometric analysis documented that the nano-fat was positive to CD 90, 73, 44, 45 and 34.

CONCLUSION

In a comparison between AFG protocol to the conventional methods in the treatment of acute burn wounds, AFG protocol was associated with significant clinical improvement in the form of lower hospital stay time, lower incidence of scaring or contracture and lower skin grafting use which was confirmed by serial photographic and histological assessment.

Resurfacing in Facial Burn Sequelae Using Parascapular Free Flap: A Long-Term Experience

BACKGROUND

It is difficult to treat large post burn sequelae (scars and defects) over face. Available methods include skin grafts, local flaps, tissue expansion, and free flaps. These surgical options should be chosen wisely, depending upon individual patient requirements and area involved. In patients with large post burn scars and defects in which the surrounding tissue is also involved, use of free tissue transfer is extremely useful.

PATIENTS AND METHODS

A retrospective analysis was done between 2011 and 2019 of fifty-two cases with extensive facial burn deformities in whom secondary reconstruction was done with free parascapular flap cover in or department. Outcome was assessed by direct questionnaire.

RESULTS

There was no complete flap loss in the series. Two cases were re-explored for venous insufficiency and suffered partial marginal necrosis. Twenty patients had to undergo further debulking procedure. Forty-seven patients were satisfied by the final outcome.

CONCLUSION

Post burn facial deformities are difficult to treat, in many cases there are no local options and tissue from different regions is to be used for reconstruction. Free parascapular flaps can be used as an effective method in such cases with a high level of patient satisfaction.

Recent strategic approach in postburn extremity scars and contractures

This study aims to present the outcomes from current alternative treatment modalities combined with the conventional techniques used in the treatment of burn contractures. Twenty-nine patients were included in the study. Patients were divided into three groups according to the severity of contractures: 1- mild, 2- moderate, and 3- severe. Skin defects that occurred following the incision and scar contracture release were closed with a collagen-elastin acellular dermal matrix (ADM). The split-thickness skin graft was evenly placed on the ADM and fixed with absorbable sutures. The grafts were closed with NPWT (negative pressure wound therapy system) dressings. In platelet-rich plasma (PRP) mild cases as well as moderate and severe PRP cases, stem cell and fat injection were applied. PRP injection was applied to the scar base before the contracture; fat injection and stem cells were applied at the 3rd and 6th months. Preoperative and postoperative range of motion (ROM), Patient and Observer Scars Evaluation Scale (POSAS), and histopathological scores were evaluated. There was a statistically significant decrease in postoperative POSAS scores (p < .05) and a significant increase in the ROM score (p < .05). Histopathological examination revealed an increased postoperative collagen accumulation and organization, increased vascularization, decreased scar tissue thickness and increased subcutaneous tissue thickness. There was no difference in treatment outcomes between the groups.Based on the current findings, we conclude that ADM, stem cell-rich fat grafting, and PRP therapies combined with conventional methods could satisfactorily improve functional outcomes in the repair of burn contractures.

Antegrade Foreheadplasty: A Novel Surgical Approach for Upper Eyelid Contracture Deformities in Pediatric Patients

The intricate and delicate structure of the periorbital region, particularly in pediatric patients, presents challenges to eyelid reconstruction. Much like the more common lower eyelid ectropion, upper eyelid ectropion can result from lack of tissue, scar contracture, or over-resection as in blepharoplasty. In burns and trauma, the cause of cicatricial ectropion is typically direct scar contracture from injuries to the eyelid. However, in some cases, extrinsic wounds involving contracture to the forehead or eyebrow can result in upper eyelid cicatricial ectropion. Direct reconstruction and skin grafting of the eyelid present complex challenges, especially in the acute inflammatory phase of traumatic injury and burn care. Furthermore, in many of these cases the periorbital and lamellae anatomy is preserved, but rather severely displaced due to scar contracture forces. The authors discuss our experience with treatment of extrinsic upper eyelid cicatricial ectropion in a series of 4 pediatric patients with burns or trauma to the forehead and periorbital regions. In all 4 cases, the antegrade foreheadplasty procedure helped to provide globe coverage, while avoiding skin matching difficulties and the intrinsic risks of operating on the eyelid during the acute phase of recovery. There is currently very limited data for the use of this technique to correct such defects. With this study, the authors hope to establish the antegrade foreheadplasty as a reconstructive option for a select patient population.

Thin and Ultra-Thin Split-Thickness Skin Grafts Are Safe and Efficacious in the Burn Population

Split-thickness skin-grafts are a mainstay of burn management. Studies suggest no benefit to using thick (0.025 inch) over standard (0.012-0.020 inch) grafts, and some support the use of thin (0.008 inch) over standard thickness. Data on the use of even thinner grafts is scarce. This study reviewed outcomes of burn patients treated with thin (0.008-0.011 inch) and ultra-thin (≤0.007 inch) grafts. Retrospective review of records from July 2012 to June 2016 included patients who sustained operative burns treated by a single surgeon. Patients were excluded for nonoperative injuries, inhalational injuries, or prolonged hospitalizations. Outcome measures were compared between thin and ultra-thin groups. One-hundred twenty-eight patients met inclusion criteria; 35 received thin split-thickness skin-grafts while 93 received ultra-thin. Cohort analysis demonstrated equivalent graft-take, time to reepithelialization, and functional outcomes. Time to donor-site healing was significantly faster in the ultra-thin cohort (P = .04). Of those with functional outcomes recorded, 88.1% had good-excellent function and 11.9% retained a limitation in function as designated in physical therapy notes. There were fewer complications overall (P = .004) and a lower incidence of hypertrophic scarring (P = .025) in the ultra-thin cohort. This study presents a single-surgeon experience with thin and ultra-thin split-thickness skin-grafts. These grafts are exhibit excellent graft-take and few complications. There was no correlation between thickness and functional outcome at the time of physical therapy discharge. Donor-site reepithelialization was faster with ultra-thin grafts, which may be important in patients with large burns and limited donor sites.

Reconstruction of Severe Burns to the Breast in Pediatric Patients: A 10-Year Experience

The breast and anterior chest are the most commonly burned part of the trunk. Burn injuries to the breast can be associated with pain, asymmetries, and significant social stigma. Burns to the breast bud in the young female may inhibit normal breast development and result in either significant asymmetries or amastia, making the treatment of breast burn injuries challenging. A retrospective chart review was conducted on all female patients under the age of 21 years admitted to our institution for breast burn injuries from January 1, 2008 to December 30, 2018. Patients were included if they had follow-up reconstructive procedures for breast burn injuries many days after their acute-phase treatment. Ninety-six patients aged 1 to 20 years have been admitted to our institution with burned breast injuries. The mean age of this cohort (n = 96) was 6.4 ± 4.8 years with a mean percent TBSA of 36.3 ± 21.4 and a mean time since injury from admission of 2279.1 ± 2284.1 days. Flame burns (66.8 percent) were the most common etiology for breast burn injuries, followed by scald burns (22.8 percent), in this cohort. The mean body mass index was 22.7 ± 6.3 kg/m2. Follow-up for reconstructive procedures was 7.2 ± 5.6 years after injury date. Our institution's 10-year experience of 96 female patients with severe burn injuries has enhanced our understanding of reconstructive techniques. The location, size, anatomic extent, type of deformity, and symmetry must all be assessed before any treatment plans, which may need to include a combination of modalities.

Impact of a Laser Service Line for Burn Scar on a Dedicated Burn OR's Flow and Productivity

Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn center's dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.

Ocular Considerations in Face Transplantation: Report of 2 Cases and Review of the Literature

PURPOSE

Periorbital injuries are common in face transplantation (FT) candidates. It is therefore essential that the ophthalmologist play a central role in the multidisciplinary treatment of these patients. In this study, the authors perform a comprehensive review of all procedures involving periorbital components, provide an update for the ophthalmology community regarding the current state of the field, and present 2 cases.

METHODS

A comprehensive review of the literature for all FT procedures including periorbital components was performed. The authors also present 2 patients who received FT including periorbital components for extensive facial disfigurement. One patient sustained high-energy avulsive ballistic injury and underwent a total face, double jaw, and tongue transplant in 2012. The second patient received a total face, eyelids, ears, and skeletal subunits transplant for extensive facial burns in 2015.

RESULTS

Literature review demonstrated that 22 (54%) of the 41 patients undergoing FT received allografts containing periorbital components. Only 14 cases (64%) reported on the presence of ocular and periocular complications. The most common complications consisted of lower eyelid ectropion and lagophthalmos, and nearly all required revisional procedures. Both patients presented with significant periorbital scarring and demonstrated good visual acuity and aesthetic outcomes at postoperative follow up between 6 and 28 months.

CONCLUSIONS

Face transplantation can address extensive facial and periorbital disfigurement with satisfactory functional and aesthetic outcomes. The majority of FT performed to date have included periorbital components, and postoperative ocular and periocular complications are common. It is critical for ophthalmologists to play a central role in the care of these patients.

Effect of extracorporeal shock wave therapy on improving burn scar in patients with burnt extremities in Isfahan, Iran

Background:

Pathologic scarring is a common problem after burn injury that has functional and esthetic limitations. Conservative and surgical treatments available for these scars are not always satisfactory. Extracorporeal shock wave therapy (ESWT) is a noninvasive modality that has proven positive effects on burn scars and wound healing in few studies. This study was conducted to evaluate the effects of ESWT on improving burn scar in extremities.

Materials and Methods:

This study was a prospective quasi-experimental on burn patients with burn scar in their extremities that underwent ESWT sessions once a week for 6 weeks. For evaluating pain and itching, visual analog scale (VAS) and for scar appearance, Vancouver Scar Scale (VSS) were used. These scales were measured and compared at the beginning of the treatment, at the end of the treatment, and 1 and 3 months after the end of the intervention.

Results:

In this study, 17 patients were treated with ESWT with a mean age of 37.94 ± 7.25 years that 47.1% of them were male. The mean of VAS score for pain and itching and VSS score were decreased significantly after the treatment and during follow-ups (All P < 0.001).

Conclusion:

ESWT can improve the pain, itching, and appearance of the burn scar in human extremities in burn patients.

Patient satisfaction after fractional ablation of burn scar with 2940nm wavelength Erbium-Yag laser

OBJECTIVE

Fractional laser therapy is a new treatment with potential benefit in the treatment of burn scars. We sought to determine patient satisfaction after burn scar treatment with the Erbium-Yag laser.

METHODS

We performed a telephone survey of all patients who underwent fractional resurfacing of burn scars with the Erbium-Yag 2940 wavelength laser at Parkland Hospital from 01/01/2016 to 05/01/2017. Subjects were asked to rate their satisfaction with their scars' after treatment characteristics on a scale from 1 (completely unsatisfied) to 10 (completely satisfied). Subjects were also asked to assess their treatment response using the UNC 4P Scar Scale before and after treatment.

RESULTS

Sixty-four patients underwent 156 treatments. A survey response rate of 77% (49/64) was seen (age: 36.8+21 years; surface area treated=435+326cm²; 35% of burn scars were >2 years old; mean scar age of 1.02+0.4 years). Overall, 46/49 (94%) of patients reported some degree of scar improvement after treatment. Patient satisfaction scores were 8.3+2.3. Number of laser treatments included: 1 (31%), 2 (33%), 3 (18%), 4(10%), >5 (8%). Treatment depth, scar age, and number of laser procedures were not significant predictors of satisfaction or UNC 4P Scar scores. The paired t-test showed a significant reduction on each of the UNC 4P Scar scale items (pain, pruritus, pliability, paresthesia). One subject reported that she felt that the laser treatment made her scar worse (2%).

CONCLUSION

Burn patients treated with the Erbium-Yag laser are highly satisfied with changes in their burn scars.

Head and Neck Reconstruction

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

Postburn Contractures of the Elbow and Heterotopic Ossification

Postburn contractures of the elbow are uncommon debilitating sequelae of severe burn injuries, which result from thermal injury to both deep and superficial tissues. When periarticular heterotopic bone forms in association with burn injuries, severe and rigid contractures may develop that prohibit basic functions of daily living and are often refractory to nonoperative intervention. Surgical intervention is aimed at releasing or excising all pathologic anatomy limiting elbow motion. In patients with proper indications, surgical intervention can result in substantial improvement in elbow motion, allowing patients to return to activities of daily living, employment, and recreational activities.

Surgical treatment algorithms for post-burn contractures

Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistent wounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes. The principle of burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeries meet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite the benefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completely and reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flap surgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects, and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods are presented. These treatment algorithms should aid in achieving significant improvement in both joint motions and aesthetic deformities.

Activating β-catenin signaling in CD133-positive dermal papilla cells increases hair inductivity

Bioengineering hair follicles using cells isolated from human tissue remains a difficult task. Dermal papilla (DP) cells are known to guide the growth and cycling activities of hair follicles by interacting with keratinocytes. However, DP cells quickly lose their inductivity during in vitro passaging. Rodent DP cell cultures need external addition of growth factors, including WNT and BMP molecules, to maintain the hair inductive property. CD133 is expressed by a subpopulation of DP cells that are capable of inducing hair follicle formation in vivo. We report here that expression of a stabilized form of β-catenin promoted clonal growth of CD133-positive (CD133+) DP cells in in vitro three-dimensional hydrogel culture while maintaining expression of DP markers, including alkaline phosphatase (AP), CD133, and integrin α8. After a 2-week in vitro culture, cultured CD133+ DP cells with up-regulated β-catenin activity led to an accelerated in vivo hair growth in reconstituted skin compared to control cells. Further analysis showed that matrix cell proliferation and differentiation were significantly promoted in hair follicles when β-catenin signaling was up-regulated in CD133+ DP cells. Our data highlight an important role for β-catenin signaling in promoting the inductive capability of CD133+ DP cells for in vitro expansion and in vivo hair follicle regeneration, which could potentially be applied to cultured human DP cells.

Bifurcated Superficial Temporal Artery Island Flap for the Reconstruction of a Periorbital Burn: An Innovation

Background:

Facial burns represent between one-fourth and one-third of all burns. The long-term sequelae of periorbital burns include significant ectropion and lagophthalmos as a result of secondary burn contractures in the lower and upper eyelids, in addition to complete or incomplete alopecia of the eyebrows.

Methods:

A retrospective study of 14 reconstructive procedures for 12 postburn faces was conducted with all procedures performed since 2010 at the Department of Plastic Surgery, Al-Hussein University Hospital, and at the Craniofacial Unit, Nasser Institute Hospital. Four patients experienced chemical burns, and 8 patients experienced thermal burns. All patients underwent periorbital reconstruction using a bifurcated superficial temporal artery island flap to reconstruct the eyebrows, correct the lagophthalmos, and release the ectropion in both the upper and the lower eyelids. Two patients underwent bilateral periorbital flap reconstruction. The mean age of patients was 29 years, and the study was conducted on 8 males and 4 females. Patient satisfaction was assessed using a questionnaire completed by all patients postoperatively.

Results:

The complete release of both the upper and the lower eyelids was achieved in all cases, together with ideal replacement of brow hair; no complications were noted, apart from one case in which a loss of hair density in the new eyebrow was observed, combined with the partial loss of the flap in the lower eyelid. Patient satisfaction results were collected and assembled in a table.

Conclusion:

A bifurcated superficial temporal artery island flap is an innovative flap for reconstructing both burned eyebrows and eyelids.

Wound healing after thermal injury is improved by fat and adipose-derived stem cell isografts

Patients with severe burns suffer functional, structural, and esthetic complications. It is important to explore reconstructive options given that no ideal treatment exists. Transfer of adipose and adipose-derived stem cells (ASCs) has been shown to improve healing in various models. The authors hypothesize that use of fat isografts and/or ASCs will improve healing in a mouse model of burn injury. Twenty 6 to 8 week old C57BL/6 male mice received a 30% surface area partial-thickness scald burn. Adipose tissue and ASCs from inguinal fat pads were harvested from a second group of C57BL/6 mice. Burned mice received 500 μl subcutaneous injection at burn site of 1) processed adipose, 2) ASCs, 3) mixed adipose (adipose and ASCs), or 4) sham (saline) injection (n = 5/group) on the first day postinjury. Mice were followed by serial photography until being killed at days 5 and 14. Wounds were assessed for burn depth and healing by hematoxylin and eosin (H&E) and immunohistochemistry. All treated groups showed improved healing over controls defined by decreased wound depth, area, and apoptotic activity. After 5 days, mice receiving ASCs or mixed adipose displayed a non-significant improvement in vascularization. No significant changes in proliferation were noted at 5 days. Adipose isografts improve some early markers of healing postburn injury. The authors demonstrate that addition of these grafts improves specific structural markers of healing. This improvement may be because of an increase in early wound vascularity postgraft. Further studies are needed to optimize use of fat or ASC grafts in acute and reconstructive surgery.

Preliminary results in single-step wound closure procedure of full-thickness facial burns in children by using the collagen-elastin matrix and review of pediatric facial burns

BACKGROUND

Management of full-thickness facial burns remains one of the greatest challenges. Controversy exists among surgeons regarding the use of early excision for facial burns. Unfortunately, delayed excision of deeper burns often results in more scarring and subsequent reconstruction becomes more difficult. A collagen-elastin matrix is used to improve the quality of the reconstructed skin, to reduce scarring and to prevent wound contraction. It serves as a foundation for split thickness skin graft and enhances short and long-term results.

AIM

We report the usage of a collagen-elastin matrix during single-step wound closure technique of severe full-thickness facial burns in 15 children with large burned body surface area, and also we review the literature about pediatric facial burns.

RESULTS

There were 15 pediatric patients with severe facial burns, 8 girls and 7 boys ranging in age from 10 months to 12 years, mean age 7 years and 6 months old. The facial burn surface area (FBSA) among the patients includes seven patients with 100%, five with 75%, and three with 50%. The average total body surface area (TBSA) for the patients was 72%, ranging between 50 and 90%. 5 of the patients' admissions were late, more than four days after burns while the rest of the patients were admitted within the first four days (acute admission time). The burns were caused by flame in eight of the patients, bomb blast in four, and scalding in three. All patients were treated by the simultaneous application of the collagen-elastin matrix and an unmeshed split thickness skin graft at Turgut Özal Medical Center, Pediatric Burn Center, Malatya, Turkey. After the treatment only two patients needed a second operation for revision of the grafts. All grafts transplanted to the face survived. The average Vancouver scar scales (VSS) were 2.55±1.42, ranging between one and six, in the first 10 of 15 patients at the end of 6 months postoperatively. VSS measurements of the last 5 patients were not taken since the 6 months postoperative period was not over.

CONCLUSION

In regard to early results, graft quality was close to normal skin in terms of vascularity, elasticity, pliability, texture and color. Esthetic and functional results have been encouraging. This study shows us that the collagen-elastin matrix as a dermal substitute is a useful adjunct, which may result in quick healing with satisfying esthetic and functional results. It also may enhance short and long-term results in after burn facial wound closure in children.

Ablative fractional laser resurfacing helps treat restrictive pediatric scar contractures

Conventional management of debilitating pediatric scar contractures, including hand therapy and surgery, may often be beset by delayed treatment, suboptimal results, and additional surgical morbidity. Ablative fractional laser resurfacing is an emerging adjunctive procedural option for scar contractures because of its promising efficacy and safety profile. However, its use to improve function has not been studied in the pediatric population. Herein we report 2 pediatric patients with recalcitrant scar contractures, causing persistent functional deficits, treated with an ablative fractional laser protocol. Both patients experienced rapid and cumulative subjective and objective improvements in range of motion and function as measured by an independent occupational therapist without reported complications. We highlight ablative fractional laser resurfacing as a novel and promising tool in the management of function-limiting scar contractures in children and propose that the technique be incorporated into existing scar treatment paradigms, guided by future research.

Management of neck contractures by single-stage dermal substitutes and skin grafting in extensive burn patients

Purpose

Severe neck contracture is a problem that must be resolved by priority. We consider the best contracture treatment to be the full-thickness skin graft. However, clinicians often encounter patients, especially extensive burn patients, who have insufficient donor sites for the full-thickness skin graft. We treated extensive burn patients with neck scar contractures with a split-thickness skin graft (STSG) combined with dermal substitutes. The purpose of this study was to evaluate clinical outcomes of neck contracture treatment in extensive burn patients performing STSG with dermal substitutes as adjuvant treatment.

Methods

We analyzed the retrospective clinical and photographic records of 28 patients with severe neck contracture who were admitted to Hallym University Hangang Sacred Heart Hospital, Seoul, Korea, from January 2012 to December 2012. We performed STSG in combination with dermal substitutes to minimize the degree of contracture.

Results

The overall take rate of skin to dermal substitutes was 95.9%, and no grafts failed to affect recontracture except in one patient with a partial loss of artificial dermis who underwent a follow-up skin graft without any problems. Excellent/good outcomes were shown in 27 out of 28 patients.

Conclusion

In extensive burn patients, skin grafting in combination with dermal substitutes can be an alternative to STSG alone for contracture release.

Custom-made approach to a patient with post-burn breast deformity

Second and third degree burns on breasts at preadolescent period may cause severe breast deformations. This deformation can be variable depending on severity and location of the burns, personal adolescent patterns, and treatment modality in acute burn period. A 21 year old female patient admitted to our department for her breast deformation due to burn contracture at the inferior pole of the right breast. On physical examination we defined that development of the volume of the right breast was equal to the left, and inferior pole of the right breast was flattened due to contracture, and nipple was projected to inferior. We found that inframammary crease of the right breast was 2 cm lower than that of left; andthe distance of nipple-inframamary crease was 4.7 cm while areola-inframmary crease was 2 cm. New nipple-areola complex level was identified according to left breast's level. Medial and lateral lines were planned to merge inferiorly at 2 cm above inframmary crease in a plan similar to vertical mammaplasty. Superior pedicle carrying nipple areola was desepitelised. Lower parenchymal V flap was transposed superiorly and attached to the pectoral muscle. Inferior parts of the lateral and medial glandular flaps were excised to form new inframammary crease. The desired laxity of skin at the lower pole was obtained by performing a new Z- plasty between lateral and medial skin flaps. Breast symmetry was confirmed by postoperative objective measurements between left and right breasts. Patient's satisfaction and aesthetic appearance levels were high. Breasts deformation patterns caused by burns, trauma and mass exsicion due to cancer could not be addressed with traditional defined techniques. Special deformations can be corrected by custom made plannings as we presented here.

Ablative fractional resurfacing for the treatment of traumatic scars and contractures

After a decade of military conflict, thousands of wounded warriors have suffered debilitating and cosmetically disfiguring scars and scar contractures. Clearly, there is a need for effective scar treatment regimens to assist in the functional and cosmetic rehabilitation of these patients. Traditional treatments, including aggressive physical and occupational therapy and dedicated wound care, are essential. Adjunctive treatments with established laser technologies, such as vascular lasers and full-field ablative lasers, have had a somewhat limited role in scar contractures due to modest efficacy and/or an unacceptable side effect profile in compromised skin. Refractory scar contractures often require surgical revision, which can be effective, but is associated with additional surgical morbidity and a significant risk of recurrence. Furthermore, current scar treatment paradigms often dictate scar maturation for approximately a year to allow for spontaneous improvement before surgical intervention. Since 2009, the Dermatology Clinic at the Naval Medical Center San Diego has been treating scars and scar contractures in wounded warriors and others using ablative fractionated laser technology. Although traditionally associated with the rejuvenation of aged and photo-damaged skin, our clinical experience and a handful of early reports indicate that laser ablative fractional resurfacing demonstrates promising efficacy and an excellent side effect profile when applied to the functional and cosmetic enhancement of traumatic scars and contractures. This article discusses our clinical experience with ablative fractional resurfacing and its potential prominent role in rehabilitation from traumatic injuries, including a possible shift in scar treatment paradigms toward earlier procedural intervention. Potential benefits include the optimization of scar trajectory and higher levels of full or adapted function in a more favorable time course.

Experience with corrective surgery for postburn contractures in Mumbai, India

Postburn contracture is a source of significant morbidity in India, even though its occurrence can be reduced significantly by comprehensive postburn injury care, including surgical intervention. This study investigates whether limited access to initial medical care after burn injury has been associated with increased contracture formation among lower socioeconomic class patients in Mumbai, India. During a surgical mission in Mumbai, India, patients presenting with functionally debilitating burn contractures and minimal income were surveyed for initial care received immediately after burn injury. The survey consisted of questions regarding the history of burn injury and details of any initial treatment. Demographic data were collected by chart review. Thirty-eight patients from the state of Maharashtra participated in the study (mean age 28.1 years). The most common etiology of burn injury was from kerosene stove blasts (74%), and the most common morbidities were contractures of the neck and upper extremity. On average, time elapsed since the original injury was 2.8 years. Nearly all patients sought initial medical care at hospitals (97%) with the majority receiving only dressing changes for their full-thickness or deep-dermal burns (61%). The most common reason for not seeking out delayed burn reconstruction was perceived cost (65%). Ultimately, 60 operations were performed, of which 9 (15%) developed postsurgical complications. These data suggest that a subset of lower socioeconomic class burn patients in Maharashtra received suboptimal initial intervention. Comprehensive initial therapy after burn injury may provide better outcomes and limit the number of patients requiring delayed reconstruction.

Extended lower trapezius myocutaneous flap in burn scar reconstruction of the face and neck of children

BACKGROUND

We aimed to present the use of extended lower trapezius myocutaneous flaps in children with scaring and contractures of the face and neck due to burns.

METHODS

We retrospectively reviewed the use of 12 extended trapezius myocutaneous flaps in 7 males and 4 females ranging in age from 1.5 to 7 years. An expander was embedded under the deep layer of the lower trapezius in order to ensure the integrity of the vascular network between the lower trapezius muscle and the skin. Dissection was performed at the deep layer of the supraspinous muscle where the descending branch of the transverse cervical artery passes between the deep layer of the trapezius muscle and the superficial layer of the supraspinous muscle.

RESULTS

All surgeries were performed successfully with no intraoperative complications. The flaps ranged in size from 30 × 18 cm to 38 × 22 cm. There were no postoperative complications, except for mild tip necrosis in one case. There were no donor site complications. All patients had good functional and cosmetic outcomes.

CONCLUSIONS

The extended lower trapezius myocutaneous flap is valuable in the management of burn reconstruction in the pediatric population.

[Sequelae of hand burns]

INTRODUCTION

Hand burns are common. Aesthetic and functional consequences are mixed together.

ANATOMY

Palmar and dorsal skin are very different. Palmar skin is thick and strong, dedicated to the prehension. Dorsal skin is very thin, creating a mobility plan dedicated to the flexion of the fingers.

AESTHETIC SEQUELAE

They are rarely isolated. Proximal nail retractions can occur after nail burns, with matricial exposition. We remove the scar and a full skin graft is done in order to give a normal proximal nail skin shape.

FUNCTIONAL SEQUELAE

They are fingers and wrist retractions. We often use collagen substitute to cover soft tissue defect after scar excision. Commissure retractions are treated by trident plasty.

PARTICULAR CASES

Electrical burns: we expose the case of a thumb amputation after necrosis by electrical burn, secondary treated by index policization. Children burns: the bridles appear during the growth, so we must follow this patient for a long time.

CONCLUSION

Hand burns are frequent. Functional sequelae are often important: retractions, amputations. The orthopaedic treatment of these retractions is unspecific. We often use collagen substitute in our unit. The patient must be involved in his treatment, because it is very long and difficult.

Tissue expansion and latissimus dorsi transfer for arm-thorax synechia reconstruction

Inadequate treatment of severe burn injury often results in scar contractures with subsequent functional impairment and cosmetic deformities depending on the body area involved. Arm-thorax synechia is a rare but devastating complication of burns. The authors report a case of a 17-year-old boy with subtotal arm-thorax synechia, secondary to burn contracture. Reconstruction was accomplished, in two stages, with the use of tissue expanders and a latissimus dorsi muscle flap. The postoperative course was uneventful in both stages, with complete survival of both the expanded skin and the muscle flap. Early initiation of intensive rehabilitation resulted in excellent functional outcome, while significant aesthetic improvement was also ensured. In conclusion, the combined use of tissue expansion and latissimus dorsi transfer may prove to be a very good option in the treatment of complex postburn axillary contractures. The main advantages of the suggested method are the best quality of skin provided by tissue expansion and the safe coverage of any vital structures exposed with the use of the muscle flap.

An overview of war-related thermal injuries

Thermal injuries have always been a source of morbidity and mortality in times of war. Historically, they constitute 5% to 20% of all injuries and approximately 4% mortality. Although burn patients constitute a small number of casualties, they consume a disproportionate amount of resources and require specialized care. The current conflicts in the Middle East report similar numbers for thermal injuries despite improvement in predeployment education to reduce noncombat-related burns, flame retardant military clothing, and decline of war patterns usually associated with increased thermal injuries. However, the increased use of improvised explosive devices and vehicle-borne improvised explosive devices presents a new source of potential thermal injury. Indeed, the burden of explosion-related burns has increased as has its associated Injury Severity Score. As has been the case in previous conflicts, most burns are hand and head burns. Although usually not life threatening, burns to hands and face lead to significant physical and psychologic morbidities. In this paper, we will review the currently available literature on war-related thermal injuries in Operation Iraqi and Operation Enduring Freedom. We will describe the epidemiology of burn injuries, prewar preparation to prevent and treat thermal injuries, and the assessment, triage, and final treatment of burn patients. In addition, we will discuss the associated physical and psychologic morbidities and, finally, the role of plastic surgeon in burn rehabilitation and reconstruction.

Nanoscale particle therapies for wounds and ulcers

‘Small is beautiful’ – this should be the slogan of nanoscientists. Indeed, working with particles less than 100 nm in size, nanotechnology is on the verge of providing a host of new materials and approaches, revolutionizing applied medicine. The obvious potential of nanotechnology has attracted considerable investment from governments and industry hoping to drive its economic development. Several areas of medical care already benefit from the advantages that nanotechnology provides and its application in wound healing will be reviewed in this article.